United States

Background: Multiple studies have shown that a majority of community-acquired pneumonia (CAP) associated mortalities are due to cardiovascular disorders. Up to 30 % of patients with CAP are at risk of cardiovascular complications during the first thirty days of hospital admission, especially older than 65 years or with underlying cardiac conditions. However, mechanisms involved in this pathogenesis are not fully understood in younger healthy patients. We are presenting a case of acute onset of systolic heart failure in the setting of community-acquired pneumonia.

Case Presentation: A 45-old male patient presented to the emergency department with a complaint of upper respiratory tract infection symptoms of 4 days duration. He received oseltamivir but worsening of symptoms, including nausea and vomiting, were noted. Vital signs were normal except for tachycardia, and the physical exam was non-focal. FLU A and B and COVID-19 testing were negative. Chest x-ray (CXR) revealed right lower lobe infiltrates. The patient was started on Levofloxacin for CAP coverage. The patient was stable, but on day three, oxygen desaturation (85%) with tachycardia and dyspnea were found. Physical examination revealed bilateral coarse crackles, especially lower lobes. CT angiography Chest ruled out pulmonary embolism but revealed diffuse bilateral alveolar and interstitial infiltrates suspicious for vascular congestion with superimposed pneumonia. Echocardiography revealed dilated cardiomyopathy, systolic heart failure (HF) with reduced left ventricular ejection fraction to 15%, and mild to moderate mitral regurgitation. Guideline-directed medical therapy for HF was initiated. Left heart catheterization excluded significant coronary artery disease.

Discussion: We present a case of acute onset of systolic heart failure in a young immunocompetent male patient who presented with CAP. The workup for CAP includes sputum cultures, blood cultures, methicillin-resistant staphylococcus aureus PCR, legionella antigen testing, cytomegalovirus, Epstein-Barr virus IgM, herpes simplex virus type I and II, and human immunodeficiency virus were negative.


2022 AMA Research Challenge

Acute Onset of Systolic Heart Failure in The Setting of Community-Acquired Pneumonia in an Immunocompetent Patient

# Welcome everyone to ACL 2022!

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ACL 2022

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Charles Lopresto, DO

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Background
Atypical hemolytic uremic syndrome (aHUS) is a rare condition characterized by hemolytic anemia, thrombocytopenia and acute renal failure. The mechanism of aHUS consists of a genetic mutation in complement regulation incited by a strong trigger leading to uninhibited activation of the complement system. Trigger events include infection, medications, malignancy or a systemic illness that initiates inflammatory reaction like pancreatitis. We present a case of a patient that presented in an extreme hyperglycemic state with acute pancreatitis and was subsequently diagnosed with aHUS. 
Case Presentation
38-year-old obese Hispanic male with no past medical history who presented to the emergency department with altered mental status. On physical exam, he was lethargic and hemodynamically unstable. Initial labs showed metabolic acidosis with anion gap, acute kidney injury, glucose of 1500, moderate serum acetone and a hemoglobin A1C of 11.9. Lipase was 1766 (upper limit of normal 60) and computed tomography of the abdomen without contrast revealed multiple loculated fluid collections around the pancreas. His renal function progressively worsened, requiring hemodialysis. On hospital day 2, his platelet count decreased to 20 and peripheral blood smear revealed schistocytes. Heparin-induced thrombocytopenia, disseminated intravascular coagulation and viral infections from Hepatitis B, C and human immunodeficiency virus were all ruled out. Also, shiga-like toxin antigen and stool culture were negative. Given the fevers, renal failure, hemolytic anemia, thrombocytopenia and altered mental status; thrombotic thrombocytopenia purpura (TTP) was suspected and immediate plasmapheresis was initiated. He completed 11 sessions of plasmapheresis in conjunction with 11 days of methylprednisolone 40 mg every 8 hours. ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) level resulted at 43%, making aHUS more likely. The patient was then started on eculizumab with improvement in his mental status and renal function. 
Discussion
Although rare, patients can develop both TTP and aHUS, with hemolytic anemia, thrombocytopenia and acute renal dysfunction following pancreatitis. Due to the high mortality of TTP, patients should be promptly treated with plasmapheresis while awaiting results of ADAMTS13 levels. If ADAMTS13 is normal, the physician should consider aHUS as a possible diagnosis and start eculizumab as soon as possible to salvage renal function.

Acute pancreatitis causing aHUS in a patient with new-onset diabetes mellitus

Association between statin use and Morbidity-Mortality outcome in stroke patient with LDL <70 mg/dl: A retrospective study from a stroke registry

Background 
Encountering direct complications of absorbable antibiotic carriers is rare. When treating prosthetic joint infections, absorbable antibiotic calcium-sulfate beads have a superior elution profile to other traditional antibiotic loaded beads which eventually require removal. In a case of persistent polymicrobial post-operative infection, an unexpected turn of events manifested with heightened serum calcium after carrier insertion.

Case Presentation 
A 74-year-old woman with advanced osteoarthritis of the hip presented with progressive right hip pain. Right total hip arthroplasty (THA) was successfully performed; however, she developed a hip abscess, fever, and chills shortly after staple removal. Abscess cultures resulted positive for methicillin-resistant Staphylococcus aureus and Finegoldia magna. Rifampin and vancomycin were initiated, and she underwent arthroplasty revision. Despite implant exchange, continued polymicrobial infection necessitated a second revision.
A second THA revision was performed with the insertion of Stimulan calcium-sulfate antibiotic carriers to optimize control of the persisting polymicrobial infection. Rifampin therapy was continued, and daptomycin substituted vancomycin due to acute kidney injury. Post-operative day five, she was found to be hypercalcemic with corrected serum calcium peaking at 12.6 mg/dL; prior labs confirmed serum levels within normal limits. Only notable symptoms were nausea and features of delirium. A broad differential was explored for this acute abnormality. Suppressed parathyroid hormone (PTH) and vitamin D metabolites favored a PTH-independent process. Granulomatous disease was suspected as a bone biopsy showed non-caseating granuloma. Hypercalcemia of malignancy was considered, with raised suspicion for multiple myeloma as elevated monoclonal protein were found. 
Serum calcium levels and delirium improved with fluids and bisphosphonate therapy. We suspected calcium-sulfate antibiotic bead spacers as the most likely calcium source after immunofixation showed no overt evidence of monoclonal proteins, diagnostics of granulomatous disease origins remained negative, and repeat PTH, vitamin D metabolites, and PTHrP remained inconsistent with primary parathyroid or paraneoplastic-mediated processes. She was discharged with downtrending inflammatory markers and normal calcium levels.

Discussion 
Calcium-sulfate antibiotic beads are effective for managing surgical site and prosthetic joint infections; however, the risk of transient hypercalcemia remains. Further studies are necessary to determine if there is a threshold amount of calcium-sulfate antibiotic beads which correlates with higher risk of developing hypercalcemia. 


Beads of Calcium, the Culprit of Confusion

Background
Syncope is the result of cerebral hypoperfusion with underlying etiologies classified as neurally mediated, cardiac, or orthostatic hypotension. Risk stratification based on etiology of syncope is crucial since cardiac syncope is associated with increased morbidity and mortality and may have specific treatment options, whereas neurally mediated syncope and orthostatic hypotension are often benign and are treated with supportive care. It is estimated that 5-21% of syncope is of cardiac etiology. Signs and symptoms, listed with the associated positive likelihood ratio (+LR) that predict increased risk of cardiac syncope include age >35 at initial episode of syncope (3.3), history of existing heart disease (2.7-7.3), exertional syncope (1.4-15), syncope while supine (1.1-4.9), prodromal chest pain, dyspnea, or palpitations (1.9-3.8), cyanotic during episode (6.2), and abnormal ECG (2.3).

Case Presentation
A 50-year-old woman presented with syncope while walking up a flight of stairs. Syncope was preceded by palpitations, dizziness, and dyspnea. ECG demonstrated sinus rhythm, 1st degree AV block, RBBB, and LAFB without ischemic changes. CT Coronary revealed multiple perilymphatic pulmonary nodules with hilar lymphadenopathy concerning for sarcoidosis. Transthoracic echocardiogram showed normal LVEF of 66% and proximal septal wall thickening. On hospital day 2, the patient experienced syncope while supine with bradycardia to the 20s and hypotension to 70s/40s. Repeat ECG and showed complete heart block. The patient received emergent transvenous pacing along with IV dopamine and norepinephrine infusions. On hospital day 3, she received a permanent dual chamber pacemaker-defibrillator. She underwent fluorodeoxyglucose positron emission tomography (FDG-PET) and biopsy confirming the diagnosis of cardiac sarcoidosis.

Discussion
This case demonstrates the importance of recognizing signs and symptoms associated with high-risk cardiac syncope, which should prompt hospital admission and further diagnostic evaluation. After identifying cardiac syncope, it is important to determine the underlying cause which can be due to arrythmias or structural heart disease. This patient’s arrhythmogenic cardiac syncope was due to cardiac sarcoidosis, an infiltrative granulomatous disease that impacts multiple organs. Clinical manifestations of cardiac sarcoidosis occur in only 5% of patients and typically presents as conduction abnormalities, ventricular arrythmias, and heart failure. Diagnosing cardiac sarcoidosis is crucial to identify patients that will benefit from appropriate treatment.


Cardiac Sarcoidosis Presenting as Syncope due to Complete Heart Block

Background
In patients with cavitary lesions it is important to consider Aspergillosis in the differentials. In the past it was more associated in immunosuppressed patients with malignancies and HIV. However, recent studies suggest risk factors such as chronic obstructive pulmonary disease (COPD), steroid use, viral infections, and occupational risk factors should also increase the suspicion.

Case Presentation
Patient is a 56 year old male with past medical history of CAD s/p PCI, COVID-19 infection 2 months ago, and COPD who presented to the hospital due to persistent cough and fevers. His occupation involved repairing air conditioners. CT chest showed RUL cavitary lesion with thickened wall. AFB cultures were negative times three. Serum studies were negative for Cryptococcus and Blastomycosis. ANCA titers were also negative. 1,3-Beta-D-glucan assay was negative.
Bronchoscopy was performed with bronchoalveolar washings (BAL), bronchial brushings and
transbronchial biopsies; culture of washings showed growth of normal respiratory flora, acid fast smear negative. Pathology examination of transbronchial biopsies showed inflammation but no malignant cells noted. Positive Aspergillus galactomannan antigen was found in BAL, and Aspergillus growth in the pulmonary cavitary lesion was confirmed. Patient was started on Voriconazole.

Discussion
In patients presenting with upper respiratory symptoms and cavitary lesion on imaging it is important to consider fungal infections like Aspergillosis, especially in patients who were treated for COVID-19 infection. Our patient also had underlying emphysematous bullous changes due to long term tobacco use, and bullae are known as a potential risk factor for this fungal infection. His occupation working to repair air conditioners could have also put him at risk for Aspergillosis. 


Cavitary Lesion in an Immunocompetent Patient with Recent COVID-19 infection


As clopidogrel demonstrates both long-term and short-term situational benefits for morbidity and mortality, it has become one most prescribed medications in the medical field. The mechanism of clopidogrel hepatotoxicity is not known, is difficult to reproduce, and may be due to the complex hepatic metabolism of the clopidogrel molecule. Immunologic features are usually not prominent, but hypersensitivity reactions to clopidogrel have been described. We describe the case of a patient who experienced clopidogrel-induced liver injury. The patient was an elderly woman who presented to the emergency department with nausea and generalized weakness. She had 1 prehospital episode of nonbilious, non-bloody vomiting, along with hyperchromic urine and constipation for 3 days pre-hospitalization. 13 days prior to this admission she was hospitalized for a transient ischemic attack (TIA) and discharged with clopidogrel and aspirin for 21 days. She had an uncomplicated posthospital course until the onset of these new symptoms. On admission, patients showed a new-onset dramatic elevation in liver markers. Abdominal MRI revealed moderate edema along the portal triad and a HIDA scan came back normal. Acetaminophen level and hepatitis screen were noncontributory. Her liver enzymes steadily elevated to the several thousands without reasonable explanation until Clopidogrel was isolated as the cause of the patient’s liver injury, and was discontinued with success. Her liver enzymes steadily down trended with discontinuation of clopidogrel and she improved dramatically. As more tests came back inconclusive for the underlying etiology of this patient’s liver injury, and her clinical condition remained undefined. A reasonable explanation for this patient’s condition was a diagnostic challenge. This was until her relatively recent initiation of Clopidogrel was considered. Clopidogrel was the only new medication this patient began taking between her two hospitalizations, and its discontinuation was followed by dramatic success. As these medications have become a mainstay of primary care in medicine, Clopidogrel side effects are critical for providers to be aware of and to understand thoroughly as they prescribe this incredibly beneficial class of medications.



Clopidogrel: A Case Report of Suspected Drug Induced Liver Injury

Background:
A rare consequence of DRESS syndrome is eosinophilic myocarditis. Our case discusses this condition in conjunction with utilization of the lifesaving modality Extra-Corporeal Membrane Oxygenation, and treatment options.

Case Presentation:
A 30-year-old female patient with a PMHx of DM1, adrenal insufficiency, vitiligo and seizure disorder, which all developed following DRESS syndrome from lamotrigine exposure presented for chest pain. She had no prior cardiac history. EKG showed low voltage QRS. Echocardiogram revealed a small pericardial effusion, pericardial thickening, EF of 55 to 60%, and no tamponade physiology. Labs showed: BNP 4194, CRP 1.48, ESR 7, and a troponin peak of 3121. The patient was treated for acute pericarditis with colchicine and prednisone with resolution of her symptoms.
Sixteen days later, she presented back with recurrent chest pain and hypotension. Labs showed: BNP 14,981 CRP 2.94, troponin peak of 24,097. TTE showed EF 30-35%. EKG showed new RBBB and inferior q waves. Repeat TTE showed EF 10-15%. Left heart catherization revealed normal coronary arteries. Following LHC, multiple episodes of ventricular tachycardia were noted, requiring defibrillated and intubation. Following intubation, she became pulseless requiring CPR and placed on VA ECMO. The patient remained on ECMO support and was started on immunosuppressive modalities following endocardial biopsy confirming eosinophilic myocarditis. Four days after discontinuing ECMO, TTE showed EF 45% with normal RSVP.

Discussion:
DRESS is a rare and potentially life-threatening condition caused by delayed hypersensitivity reaction. Although many cardiac imaging tests assist in the diagnosis, the most definitive remains endomyocardial biopsy. This case report is unique in that there is no other case report that emphasizes the importance of early ECMO support and an anti-IL- 5 antibody in the treatment of eosinophilic myocarditis. In this case, the role of ECMO was significant in the bridge to recovery.
Typical, long-term treatments of eosinophilic myocarditis include steroids in adjunct with immunosuppressive strategies. Our patient’s regimen included prednisone daily, mycophenolate twice a day, and mepolizumab injections monthly. Eosinophils acquire IL-5 receptor on their surface during the early stages of differentiation, and maturation. Mepolizumab, is an anti-IL-5 recombinant humanized monoclonal antibody, which stops the interaction between IL-5 and its receptor on eosinophils.

DRESS Syndrome Associated Eosinophilic Myocarditis: A Rare Condition Leading to Life Saving Measures on ECMO

Background:
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is typically characterized by extensive skin rash with associated visceral organ involvement, fever, lymphadenopathy, and eosinophilia. The condition typically has a two-to-eight-week latency period in symptom development following initiation of offending drug. Additionally, hepatic injury is the most common visceral organ involved with separate long-term sequelae of DRESS including autoimmune conditions such as autoimmune thyroid disease, vitiligo, and lupus erythematosus. 

Case Presentation: 
An 18-year-old, college-attending male, with a two-month history of Bactrim use for acne treatment, presented with an eight-day history of diffuse rash without mucosal involvement. Patient initially developed a pruritic rash that responded to Zyrtec and the discontinuation of Bactrim. Patient later became febrile and the rash returned. The rash was described to start as a pink, maculopapular rash that coalesced to become more diffuse, violaceous plaques. 
The patient presented to campus health services where he was received a dose of epinephrine and methylprednisolone due to anaphylaxis concerns along with ceftriaxone for meningitis concerns, and referred to the hospital for further evaluation. His hospital workup was significant for leukocytosis without eosinophilia with accompanying transaminitis, hyperbilirubinemia, elevated lactate, and abnormal coagulation studies. Rickettsia labs and blood cultures were negative, ruling out rocky mountain spotted fever and meningococcemia. Patient also had a normal EKG and low TSH with a normal free T4. 
Given these findings and patient’s recent Bactrim use, the patient was diagnosed with DRESS and started on prednisone. Over the next few days, the transaminitis and hyperbilirubinemia improved. Given the improvement in symptoms and no new presentation of organ involvement, patient was discharged with dermatology follow-up for a steroid taper and endocrinology assessment for thyroid abnormalities secondary to or independent from DRESS. 

Discussion: 
Despite its name, DRESS can present without eosinophilia. Early recognition despite the condition’s heterogenous presentation is imperative for triaging severity of disease and treatment initiation with glucocorticoids, discontinuation of offending drug, and appropriate supportive care. Additionally, the use of Bactrim for the acne treatment should be used with caution given its association with this severe drug reaction.

DRESS vs. DRSS: The Heterogenous Presentation of Drug Reaction with Eosinophilia and Systemic Symptoms

Background:
Invasive fungal sinusitis is a rare but possibly fatal complication of Covid-19 infection. We report an extremely rare case of invasive fungal sinusitis due to an uncommon pathogen, Alternaria.

Case Presentation:
Patient is a 49-year-old female with a history of poorly controlled diabetes presenting with right maxillary fungal sinusitis with abscess. One month prior, after recovering from COVID-19 pneumonia, she developed right facial swelling, diplopia, blurry vision, and pain with extraocular movements. She was admitted at an outside hospital for diabetic ketoacidosis and facial cellulitis with right maxillary sinusitis, which was treated with piperacillin-tazobactam and vancomycin. She also received micafungin for possible fungal infection, which was discontinued after culture showed no growth at 1 week. Later, the patient had progressive facial symptoms prompting her to return to the emergency room. MRI of the orbit showed acute abscess with concerns for meningeal involvement in her right orbital structures and she was restarted on antibiotics. Fungal culture from prior admission was noted to have grown Alternaria species. She was transferred to our hospital and was treated with multiple surgical debridements and 2 weeks of voriconazole, amphotericin B, and daptomycin with improvement in her symptoms. She was discharged to a SNF to continue receiving treatment.

Discussion:
While studies on fungal sinusitis in association with COVID-19 have been limited, Mucor and Aspergillus appear to be the most common pathogens. Possible risk factors for COVID-19 associated fungal sinusitis include steroid use, diabetes, renal failure, and hypertension. 

Alternaria is a dematiaceous hyphomycete commonly involved in human infection. The most frequent clinical manifestations are cutaneous and subcutaneous infections, followed by oculomycosis, rhinosinusitis, and onychomycosis. Important risk factors include solid organ transplantation, Cushing’s syndrome, and bone marrow transplants. 

A noted complication in the care of our patient was the delayed recognition of fungal sinusitis; her fungal culture did not show growth until after discharge. Many species involved in fungal sinusitis, including Alternaria, are detected after 1 week of culture; however, fungi can be detected after longer incubation periods. In patients with multiple risk factors and COVID-19 infection, it may be important to continue monitoring for fungal isolates, even if patients are improving clinically.

Fungal Sinusitis with COVID-19: Not Always Mucor!

Haemophilus parainfluenzae is a gram-negative coccobacillus commonly found in the normal flora of the mucosal membranes of the upper respiratory tract. It has been rarely reported to cause invasive infection including meningitis, endocarditis, urinary tract infections, soft tissue infections, hepatic abscess, and epidural abscess. Osteomyelitis and septic arthritis caused by Haemophilus parainfluenzae are a rare entity with just a few cases described in the literature. 

Case Presentation
A 72-year-old man presented with a two-days of lower back pain. The pain was constant, non-radiating and worse with movement. He had a history of recurrent low back pain due to a previous L3 compression fracture and recurrent acute sinusitisepisodes. Physical exam was remarkable for tenderness to palpation of paraspinous muscle bilaterally at L3-L5 level, and limited flexion of the back due to pain. CT of the lumbar spine showed chronic changes including compression fracture and retropulsion of L3 vertebral body with moderate to severe narrowing of spinal canal. Despite been sent home with anti-inflammatories and muscle-relaxants, he continued with intractable back pain for the next two months. At this time, erythrocyte sedimentation rate was noted to be 36 mm/h and C-reactive protein 3.8 mg/dL. MRI showed concerning findings for osteomyelitis and discitis. CT guided- aspiration bone biopsy cultures grew Haemophilus parainfluenzae. He was treated with ceftriaxone for 6 weeks with improvement of symptoms. 

Discussion
Bone and joint infections caused by H. Parainfluenzae have rarely been reported in literature. From our review of the literature, most of the cases mentioned in the literature about bone and joint infections cause by H. parainfluenzae were on patients with underlying chronic conditions, bone structural abnormalities, or recent procedure. From these cases hematogenous spread or close contaminated source seems to be the most common routes of infection for Haemophilus parainfluenzae given patients history. In our case, the patient had a recent history of recurrent upper respiratory infections with an underlying bone abnormality that could have served as a reservoir for infection. Although H. parainfluenzae is a rare cause of bone infection, careful evaluation of patient’s history and possible preceding factors for infection should be considered in every patient.

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Acute Onset of Systolic Heart Failure in The Setting of Community-Acquired Pneumonia in an Immunocompetent Patient

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